Shah v. Metro. Life Ins. Co.
| Decision Date | 19 February 2019 |
| Docket Number | Case No. 2:16-cv-1124 |
| Parties | MUKESH R. SHAH, M.D., Plaintiff, v. METROPOLITAN LIFE INSURANCE COMPANY, et al., Defendants. |
| Court | U.S. District Court — Southern District of Ohio |
OPINION AND ORDER
This matter is before the Court on the Motion for Partial Summary Judgment of Defendants The Paul Revere Life Insurance Company and Metropolitan Life Insurance Company. (Defs.' Mot. Partial Summ. J., ECF No. 61). For the reasons that follow, Defendants' motion is GRANTED.
On September 10, 1991, New England Mutual Life Insurance Company issued an individual disability insurance policy to Plaintiff Dr. Mukesh Shah identified as Policy No. 191D218095 (the "Policy"). (Answer to Am. Compl. ¶ 5, ECF No. 27 at 174). Dr. Shah was an interventional cardiologist at the time he applied for the Policy. (Am. Compl. ¶ 16, ECF No. 13 at 132). Defendant Metropolitan Life Insurance Company ("Met Life") is the successor-in-interest to the Policy through its merger with New England Mutual Life Insurance Company. (Answer to Am. Compl. at ¶ 6, ECF No. 27 at 174). Defendant Paul Revere Life Insurance Company ("Paul Revere") is responsible for administering the Policy on Met Life's behalf. (Id. at ¶ 7). Met Life and Paul Revere proceed together and are collectively referred to as "Defendants."
Pursuant to the terms of the Policy, Defendants are obligated to pay certain benefits to Dr. Shah for loss due to "injury" or "sickness" until his sixty-fifth birthday. (Claim File, ECF No. 57- 1 at 784-95). Under the provisions of the "Lifetime Total Disability Benefit Rider" also purchased by Dr. Shah (the "Rider"), Defendants are further required to make benefit payments beyond Dr. Shah's sixty-fifth birthday if he suffered "total disability" prior to age 65 and such disability continued until age 65. (Id. at 800). The Rider provides that if Dr. Shah's disability is due to "injury," Defendants are obligated to pay him the Maximum Monthly Amount. (Id. at 786, 800). Whereas if Dr. Shah's disability is due to "sickness," Defendants are only obligated to pay him according to a certain factor, which is a fraction of the Maximum Monthly Amount determined by Dr. Shah's age at the time of his "total disability" due to "sickness." (Id. at 800). The Policy also recognizes that a disability may be caused by both "sickness" and "injury" and promises to pay the largest benefit available. (Id. at 791, ¶ 6.2).
Under the Policy, "injury" is defined as "accidental bodily injury sustained after the Date of Issuance and while Your Policy is in force." (Id. at 784, ¶ 1.5). "Sickness" is defined as (Id. at 784, ¶ 1.6).
Dr. Shah first experienced symptoms in 2005, "especially in his left shoulder down to his left triceps area," (Defs.' Ex. E, ECF No. 62-5 at 5462) and "presented with a clinical history of left cervical radiculopathy with finger numbness and pain after playing golf" to his initial treating physician, Dr. Grandinetti. (Defs.' Ex. D, Grandinetti Aff. ¶ 4, ECF No. 62-4 at 5452). Dr. Grandinetti performed an MRI of Dr. Shah's cervical spine and concluded that Dr. Shah had a disk protrusion, joint spur, and foraminal narrowing in each of the C4-C5, C5-C6, and C6-C7 vertebrae. (Id. at ¶ 5). Another physician, Dr. Cibula, reviewed the MRI and Dr. Grandinetti's findings and"stated that the MRI 'does show an ostephyte at C-6-7.'" (Id. at ¶ 7). Dr. Cibula further determined that Dr. Shah's condition was "mostly chronic, although certainly the history supports an acute inflammation superimposed on a chronic process." (Id.). Dr. Grandinetti later confirmed that Dr. Cibula's findings were consistent with his initial examination. (Id. at ¶ 9, 5453). A few weeks later, Dr. Uselman further assessed Dr. Shah and determined, "Dr. Shah does have a C6-7 disc herniation with a C7 radiculopathy." (ECF No. 62-5 at 5463).
On February 29, 2012, Dr. Shah sought treatment for bilateral shoulder pain. (Defs.' Ex. F, ECF No. 62-6 at 5465). Dr. Nowinski, a board-certified orthopedic surgeon, diagnosed Dr. Shah with bilateral rotator cuff tears, biceps tendon tears, and bilateral rotator cuff syndrome with impingement and acromioclavicular ("AC") joint arthropathy and recommended surgical treatment. (Id. at 5466). On March 2, 2012, Dr. Nowinski performed shoulder surgery on Dr. Shah's right side. (Defs.' Ex. G, ECF No. 62-7). In his operative report, Dr. Nowinski noted that Dr. Shah, "presents with the gradual onset of progressive pain and dysfunction of the right shoulder." (Id. at 5470). Following the initial surgery on his right side, Dr. Shah fell from a bicycle and fractured his left clavicle and dislocated his left AC joint. (Defs.' Ex. V, ECF No. 62-22 at 5541).
During the subsequent shoulder surgery on his left side in May 2012, his clavicle fracture and dislocated AC joint were also repaired. (Id.). Dr. Shah returned to work after the second surgery. (Id.). On July 30, 2012, Dr. Shah was reevaluated by Dr. Nowinski, who noted, "the clavicle is well healed." (Defs.' Ex. K, ECF No. 62-11 at 5479). During a second reevaluation on November 19, 2012, Dr. Nowinski once again noted that Dr. Shah's clavicle was, "well healed" and in "good alignment and position." (Defs.' Ex. L, ECF No. 62-12 at 5483).
On January 22, 2013, Dr. Shah saw Dr. Uselman for his neck pain. (Defs.' Ex. AC, ECF No. 62-29 at 5580). Upon reviewing Dr. Shah's MRI, Dr. Uselman noted, "neck pain with radiation into the left arm getting progressively worse." (Id.). Dr. Uselman recommended physical therapy treatment and an MRI of the cervical spine. (Id.). On September 6, 2013, Dr. Shah saw Dr. Flood, a rheumatologist, for severe neck and scapular pain. (Id. at 5581). Dr. Flood recommended an injection in Dr. Shah's left shoulder to treat his pain. (Id.). On September 9, 2013, an MRI showed degeneration in multiple areas of the cervical spine. (Id.). On September 10, 2013, Dr. Shah returned to Drs. Nowinski and Uselman. (Id.). Dr. Nowinski suggested he consider modifying his career, and Dr. Uselman recommended he stop doing interventional cardiology altogether. (Id.). On September 11, 2013, Dr. Shah saw Dr. Lang, a neurologist. (Id.). Dr. Lang also noted degenerative disk disease progression and bilateral issues exacerbated by Dr. Shah's work in the catheterization lab. (Id.).
On September 12, 2013, Dr. Shah became disabled due to shoulder and cervical spine pain and was unable to continue practicing as an interventional cardiologist. (Am. Compl. ¶ 17, ECF No. 13 at 132). On October 24, 2013, Dr. Shah gave notice of his condition and of a claim under the Policy to New England Mutual Life Insurance Company. (Id. at ¶ 15, ECF No. 3 at 61). On June 5, 2014, Defendants approved Dr. Shah's request for individual disability benefits and informed him that factors for "total disability" due to "sickness" may apply. (Defs.' Ex. T, ECF No. 62-20 at 5521-22). On July 7, 2014, Dr. Shah asked Defendants to confirm that his condition resulted from "injury" with lifetime benefits. (Defs.' Ex. U, ECF No. 62-21 at 5531).
On August 21, 2014, Paul Revere sent Dr. Shah's medical records to Dr. Beavers, who is board certified in internal medicine and occupational medicine. (Defs.' Ex. V, ECF No. 62-22 at 5535). After reviewing Dr. Shah's records, Dr. Beavers concluded that Dr. Shah's "condition ofcervical degenerative disc disease and radiculopathy is chronic and degenerative in nature and not related to any acute traumatic event." (Id. at 5442). On August 27, 2014, Dr. Beavers contacted Dr. Nowinski to discuss Dr. Shah's medical condition. (Defs.' Ex. W, ECF No. 62-23 at 5545). Dr. Beavers summarized their conversation by noting that Dr. Shah's clavicle and AC joint have healed and further stating that "Dr. Nowinski indicated that Dr. Shah's bilateral rotator cuff tears were pre-existing, chronic and degenerative generations." (Id. at 5543). Dr. Beavers also remarked that Dr. Shah's "present inability to work is related both to residual symptoms from the bilateral shoulder conditions and a recurrence of a pre-existing cervical radiculopathy, all of which are chronic, degenerative conditions and not related to an acute traumatic event." (Id.).
On October 7, 2014, Dr. Nowinski responded by providing a sworn declaration stating, "Dr. Shah's condition is related to injury, the cumulative effects of years of standing for long hours in the catheterization lab in ergonomically unsound positions while bearing the weight of heavy personal protective apparel, as complicated by his left clavicle fracture and surgery, which have led to his orthopedic problems." (Claim File, ECF No. 57-10 at 4861). On November 6, 2014, Paul Revere sent Dr. Shah's records to Dr. Kanovsky, a board-certified orthopedic surgeon, for further review. (Defs.' Ex. Y, ECF No. 62-25). On November 13, 2014, Dr. Kanovsky found that "Dr. Nowinski agreed that the condition is not related to any acute traumatic event, but now argues that his condition is related to 'the cumulative effects of years of' working in the catheterization lab." (Id. at 5552). Dr. Kanovsky further stated, "My conclusion was that the insured's condition of cervical degenerative disc disease and radiculopathy was chronic and degenerative in nature and not related to any acute traumatic event, and that, while this condition would be expected to be exacerbated by intensive and repetitive upper extremity activity, I do not conclude that these movements are traumatic or injurious." (Id.). Dr. Kanovsky opined, "There is not any evidence inthe medical records or articles submitted by the claimant that the lead aprons were the cause of the DDD...
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